Provider Demographics
NPI:1437118361
Name:DESAI, MITUL
Entity Type:Individual
Prefix:
First Name:MITUL
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 WILMOT RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5145
Practice Address - Country:US
Practice Address - Phone:847-580-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084144207R00000X
IL036108781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4796385Medicaid
MI110F376980OtherBCBSM
MIH94101Medicare UPIN
MI4796385Medicaid